Using a Knowledge-Based Clinical Decision Support System to Reduce the Time to Appropriate Antimicrobial Therapy in Hospitalized Patients With Bloodstream Infections: A Single-Center Observational Study

BACKGROUND

Inappropriate antimicrobial use is a crucial determinant of mortality in hospitalized patients with bloodstream infections. Current literature reporting on the impact of clinical decision support systems on optimizing antimicrobial prescription and reducing the time to appropriate antimicrobial therapy is limited.

METHODS

Kaohsiung Veterans General Hospital implemented a hospital-wide, knowledge-based, active-delivery clinical decision support system, named RAPID (Real-time Alert for antimicrobial Prescription from virtual Infectious Diseases experts), to detect whether there was an antimicrobial agent-pathogen mismatch when a blood culture result was positive. Once RAPID determines the current antimicrobials as inappropriate, an alert text message is immediately sent to the clinicians in charge. This study evaluated how RAPID impacted the time to appropriate antimicrobial therapy among patients with bloodstream infections.

RESULTS

During the study period, 633 of 11 297 recorded observations (5.6%) were determined as inappropriate antimicrobial prescriptions. The time to appropriate antimicrobial therapy was significantly shortened after the implementation of RAPID (1.65 vs 2.45 hours, P < .001), especially outside working hours (1.24 vs 6.43 hours, P < .001), in the medical wards (1.40 vs 2.14 hours, P < .001), in participants with candidemia (0.74 vs 5.36 hours, P < .001), and for bacteremia due to non-multidrug-resistant organisms (1.66 vs 2.49 hours, P < .001).

CONCLUSIONS

Using a knowledge-based clinical decision support system to reduce the time to appropriate antimicrobial therapy in a real-world scenario is feasible and effective. Our results support the continued use of RAPID.

Recommendations and guidelines for the treatment of infections due to multidrug resistant organisms

Antimicrobial drug resistance is one of the major threats to global health. It has made common infections increasingly difficult or impossible to treat, and leads to higher medical costs, prolonged hospital stays and increased mortality. Infection rates due to multidrug-resistant organisms (MDRO) are increasing globally. Active agents against MDRO are limited despite an increased in the availability of novel antibiotics in recent years. This guideline aims to assist clinicians in the management of infections due to MDRO. The 2019 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group, comprising of infectious disease specialists from 14 medical centers in Taiwan, reviewed current evidences and drafted recommendations for the treatment of infections due to MDRO. A nationwide expert panel reviewed the recommendations during a consensus meeting in Aug 2020, and the guideline was endorsed by the Infectious Diseases Society of Taiwan (IDST). This guideline includes recommendations for selecting antimicrobial therapy for infections caused by carbapenem-resistant Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacterales, and vancomycin-resistant Enterococcus. The guideline takes into consideration the local epidemiology, and includes antimicrobial agents that may not yet be available in Taiwan. It is intended to serve as a clinical guide and not to supersede the clinical judgment of physicians in the management of individual patients.

Hyperbaric oxygen therapy increases the risk of tuberculosis disease

BACKGROUND

As Mycobacterium tuberculosis is an aerobic microbe, hyperbaric oxygen therapy (HBOT) could trigger progression from latent tuberculous infection (LTBI) to active tuberculosis (TB) disease.

OBJECTIVE

To evaluate the effect of HBOT on TB reactivation.

DESIGN

Our study sample was from the National Health Insurance Research Database containing one million beneficiaries. We identified a group of patients who underwent HBOT, and matched this group with individuals without HBOT. We compared the incidence of activation of TB between these two groups.

RESULTS

A total of 2258 patients were identified, with each group comprising 1129 patients. One year after exposure to hyperbaric oxygen, the number of cases of active TB was significantly higher in the HBOT group than in the non-HBOT group (11 cases vs. 1 case, P = 0.006). Multiple regression analysis showed that HBOT was the only statistically significant contributor to TB activation.

CONCLUSION

HBOT is likely to trigger the reactivation of TB. High-risk patients should undergo the tuberculin skin test or interferon-gamma release assays before HBOT to identify patients with LTBI.

Evaluation of a matrix-assisted laser desorption ionization-time of flight mass spectrometry assisted, selective broth method to screen for vancomycin-resistant enterococci in patients at high risk

BACKGROUND

Bile esculin azide with vancomycin (BEAV) medium is a sensitive, but slightly less specific method for vancomycin-resistant enterococci (VRE) screening. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) is a rapid method for identification of clinical pathogens. This study aimed to assess the performance of a novel combination screening test for VRE, using BEAV broth combined with MALDI-TOF MS.

MATERIALS AND METHODS

Clinical specimens were collected from patients at risk of VRE carriage, and tested by the novel combination method, using selective BEAV broth culture method followed by MALDI-TOF MS identification (SBEAVM). The reference method used for comparison was the ChromID VRE agar method.

RESULTS

A total of 135 specimens were collected from 78 patients, and 63 specimens tested positive for VRE positive using the ChromID VRE method (positive rate 46.7%). The sensitivity, specificity, positive predictive value, and negative predictive value of SBEAVM method after an incubation period of 28 hours were 93.7%, 90.3%, 89.4%, and 94.2%, respectively. The SBEAVM method when compared to the ChromID VRE method had a shorter turnaround time (29 vs. 48-72 hours) and lower laboratory cost ($2.11 vs. $3.23 per test).

CONCLUSIONS

This study demonstrates that SBEAVM is a rapid, inexpensive, and accurate method for use in VRE screening.

Isolation of dengue virus from the upper respiratory tract of four patients with dengue fever

Background

Dengue fever is an important arboviral disease. The clinical manifestations vary from a mild non-specific febrile syndrome to severe life-threatening illness. The virus can usually be detected in the blood during the early stages of the disease. Dengue virus has also been found in isolated cases in the cerebrospinal fluid, urine, nasopharyngeal sections and saliva. In this report, we describe the isolation of dengue virus from the upper respiratory tract of four confirmed cases of dengue.

Methods

We reviewed all laboratory reports of the isolation of dengue virus from respiratory specimens at the clinical microbiology laboratory of the Kaohsiung Veterans General Hospital during 2007 to 2015. We then examined the medical records of the cases from whom the virus was isolated to determine their demographic characteristics, family contacts, clinical signs and symptoms, course of illness and laboratory findings.

Results

Dengue virus was identified in four patients from a nasopharyngeal or throat culture. Two were classified as group A dengue (dengue without warning signs), one as group B (dengue with warning signs) and one as group C (severe dengue). All had respiratory symptoms. Half had family members with similar respiratory symptoms during the period of their illnesses. All of the patients recovered uneventfully.

Conclusions

The isolation of dengue virus from respiratory specimens of patients with cough, rhinorrhea and nasal congestion, although rare, raises the possibility that the virus is capable of transmission by the aerosol route among close contacts. This concept is supported by studies that show that the virus can replicate in cultures of respiratory epithelium and can be transmitted through mucocutaneous exposure to blood from infected patients. However, current evidence is insufficient to prove the hypothesis of transmission through the respiratory route. Further studies will be needed to determine the frequency of respiratory colonization, viable virus titers in respiratory secretions and molecular genetic evidence of transmission among close contacts.

Dengue virus is rarely identified in respiratory specimens. We retrospectively identified four patients with dengue fever who had the virus isolated from their nose or throat. All the patients had respiratory signs or symptoms. Half had family members who also had respiratory symptoms. Further studies are needed to evaluate the possibility of respiratory transmission of this virus.

A nationwide covert observation study using a novel method for hand hygiene compliance in health care

BACKGROUND

Evaluation and feedback is a core hand hygiene (HH) improvement strategy. The covert observation method avoids observation bias inherent to the overt method. The aim of the study was to observe HH compliance by a novel covert method in a real-world setting.

METHODS

We conducted a 2-year, nationwide, prospective, observational study in teaching hospitals across Taiwan. Medical students and students who may have contact with patients in their careers were recruited as participants. A novel, shorthand notation method for covert observation was used. Observation results were reported through a study website.

RESULTS

There were a total of 25,379 HH opportunities covertly observed by 93 observers. Overall HH compliance was 32.0%. Health care workers had the highest HH compliance for indication 4 (42.6%), and the lowest for indication 5 (21.7%). Overall handrubbing percentage was high, reaching 83.6%. The HH compliance increased significantly with an increase in the number of indications within 1 HH opportunity (P < .001).

CONCLUSIONS

The overall HH compliance by the covert observation method was low. An innovative shorthand notation method facilitated covert observation, and website reporting was demonstrated to be feasible for large-scale observation.

Emergence of a strain of methicillin-resistant Staphylococcus aureus with decreased susceptibility to vancomycin 7 months after treatment with glycopeptide antibiotics

This case report describes a methicillin-resistant Staphylococcus aureus isolated repeatedly from the blood of a patient with community-acquired endocarditis who developed a four-fold increase in the minimal inhibitory concentration of vancomycin and daptomycin 7 months after his last exposure to glycopeptide antibiotics. This is contrary to the expected situation in which antimicrobial resistance tends to decrease after a patient is no longer exposed to vancomycin.

Hand hygiene among patients: attitudes, perceptions, and willingness to participate

BACKGROUND

Patient participation has been proven to increase hand hygiene compliance of health care workers. The objective of the study is to better understand patients' attitudes and perceptions toward hand hygiene, and to identify patients with the highest motivation to participate in hand hygiene.

DESIGN

A 2-week, cross-sectional survey of hospitalized patients and their family members was conducted using an anonymous, self-reporting questionnaire in a large teaching hospital in Taiwan.

RESULTS

Of the 859 respondents, 89.8% considered hand hygiene important, and 75.9% would take hand hygiene practices into consideration when they choose a hospital. Most respondents (78.4%) would like more information on hand hygiene, particularly persons who have had experience with health care-associated infection (odds ratio, 2.48; 95% confidence interval, 1.57-3.89; P < .001). Respondents would be more willing to ask a doctor or nurse to wash his or her hands if they knew that the doctor or nurse would appreciate the reminder (doctor: from 48.9% to 74.6% [P < .001]; nurse: from 50.8% to 76.3% [P < .001]).

CONCLUSIONS

Hand hygiene is considered important by most patients and family members and plays an influential role in their choice of a hospital or doctor. Persons with experience with health care-associated infections have the greatest motivation to participate in hand hygiene.

Optimal treatment for asymptomatic neurosyphilis

In the pre-penicillin era, patients with asymptomatic neurosyphilis (ANS) were more likely to develop long-term neurological sequelae than those patients with normal cerebrospinal fluid (CSF). Although benzathine penicillin G cannot achieve treponemicidal levels in the CSF, decreased rates of neurological complications of syphilis and non-treponemal titre serological responses are usually observed after treatment with this antibiotic. We here a homosexual man with ANS successfully treated with benzathine penicillin G. This case suggests that reconsideration on the necessity of a lumbar puncture in HIV-infected patients with ANS is warranted.

Clinical manifestations of eosinophilic meningitis caused by Angiostrongylus cantonensis: 18 years' experience in a medical center in southern Taiwan

BACKGROUND

With the improvement of public health, eosinophilic meningitis associated with Angiostrongylus cantonensis infection is now seldom reported in Taiwan. Eosinophilic meningitis typically occurred sporadically in children. This study aims to analyze the clinical manifestations and change in the contemporary epidemiology of eosinophilic meningitis in Taiwan.

METHODS

This is a retrospective study of patients diagnosed with eosinophilic meningitis at Kaohsiung Veterans General Hospital, from December 1991 to September 2009. The demographic characteristics, clinical presentations, laboratory data, radiographic imaging, and treatment and clinical outcome were analyzed. A PubMed search with the keywords of eosinophilic meningitis, A cantonensis, and Taiwan was performed to retrieve cases of eosinophilic meningitis caused by A cantonensis since 1960.

RESULTS

Thirty-seven patients were diagnosed to have eosinophilic meningitis during a period of 18 years. The median age was 32 years (range, 2-80 years). Ninety five percent (35/37) of the patients were adults. The median incubation period was 10.5 days (range, 3-80 days). Most of the patients presented with headache (29, 78%), fever (25, 68%), and 11(30%) had hyperesthesia. Patients with hyperesthesia had longer incubation period (55 vs. 7 days, p=0.004), lower serum immunoglobulin E levels (127.5 vs. 1295 IU/mL, p<0.001), and longer duration between symptom onset and spinal taps (14 vs. 5 days, p=0.011). Three patients presented initially with lymphocytic meningitis, and eosinophilia only appeared on a second lumbar puncture. Magnetic resonance imaging of the brain disclosed leptomeningeal enhancement (17/26, 65%) and increased signal intensity (10/26, 38%) on T2-weighted and fluid-attenuated inversion recovery images. There were eight relapses and two patients died. No sequela was noted except in one 2-year-old toddler, who had weakness of both lower limbs.

CONCLUSIONS

The epidemiology of eosinophilic meningitis has changed during the past two decades in Taiwan and occurs mainly in adults in the setting of outbreaks. Hyperesthesia; repeated lumbar puncture in cases with lymphocytic meningitis of uncertain cause; and a detailed history, including food consumption, are important to establish an accurate diagnosis.

Outbreak of Salmonella enteritidis B in a family in southern Taiwan

BACKGROUND AND PURPOSE

This study describes a Salmonella outbreak in a 9-member family in Southern Taiwan, and emphasizes the risk of Salmonella infection in extreme age.

METHODS

Salmonella infection was identified by blood culture, stool swab, and Widal test. A questionnaire was designed for the family to ascertain the underlying disease, symptoms, and history of untreated water and food exposure.

RESULTS

Of 9 members in the family, 4 had symptoms of fever, abdominal pain, and watery diarrhea. There was a relationship between Salmonella infection and age, and associated symptoms included fever, nausea, diarrhea, abdominal pain, and weakness.

CONCLUSIONS

Salmonella infection tends to occur more frequently in very young or very old people, especially elderly patients with chronic pre-existing comorbidities. Therefore, age is a significant risk factor for this symptomatic disease.

Clinical manifestations of Japanese encephalitis in southern Taiwan

BACKGROUND AND PURPOSE

Japanese encephalitis virus infection is a sporadic infectious disease in Taiwan. Despite progress in laboratory examinations and imaging studies, diagnosis of Japanese encephalitis remains underestimated. This study was conducted to identify clinical symptoms and laboratory findings that may assist in early identification of this disease.

METHODS

This retrospective study included all patients diagnosed with Japanese encephalitis at Kaohsiung Veterans General Hospital from January 2000 through December 2007. Epidemiologic data, predisposing factors, neurological and non-neurological signs and symptoms, laboratory data, and treatment were analyzed. Outcomes and neurological complications were evaluated.

RESULTS

Eleven patients had Japanese encephalitis, and 10 had sufficient information for enrolment into the study. Nine patients presented with non-significant constitutional symptoms of fever, nausea, or headache. Other signs and symptoms included rhinorrhea, sore throat, abdominal pain, cough, myalgia, or arthralgia. Eight patients had lymphocytic pleocytosis with elevated protein and borderline low glucose levels in the cerebrospinal fluid. Leptomeningeal enhancement and low density lesions were the most common computed tomography findings. T2 hyperintensity lesions and leptomeningeal enhancement were seen in 5 patients. Two patients presenting with acute flaccid paralysis had high intensity lesions on the thalamus and basal ganglion. There were no correlations between clinical, laboratory, and imaging findings. None of the patients had neurological sequelae.

CONCLUSIONS

Presentations, laboratory examination, and clinical signs are not specific for Japanese encephalitis. Sporadic cases are usually seen from May to August, which are associated with monsoon rains. Hence increased awareness of this disease is recommended during these periods.

Hepatocyte growth factor level in cerebrospinal fluid as an additional marker in patient with drug-resistant streptococcus pneumoniae meningitis treated with linezolid

Hepatocyte growth factor (HGF) is a multifunctional cytokine that has well-defined mitogenic, motogenic, and morphogenic functions on the epithelial cells. Strong increases of HGF concentrations in cerebrospinal fluid (CSF) are only present in patients with acute bacterial meningitis. We report a 15-year-old young man with drug resistant Streptococcus pneumoniae meningitis complicated with right 6th cranial nerve palsy. He presented with fever, headache and neck stiffness for 3 days and was treated with intravenous antimicrobial agents including linezolid and dexamethasone successfully. An association between CSF HGF concentrations and CSF proteins is observed (r = 0.897, p = 0.039. Pearson correlation test). This result showed that HGF level in CSF might act as an additional marker in patients with bacterial meningitis.